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THE BIOPSYCHOSOCIAL MODEL AND THE

EDUCATION OF HEALTH PROFESSIONALS* t


George L. Engel
Departments of Psychiatry and Medicine
University of Rochester
Rochester, New York 14642
INTRODUCTION
Over the past 50 years medical education has grown increasingly proficient in
conveying to physicians sophisticated scientific knowledge and technical skills about
the body and its abberations. Yet at the same time it has failed to give corresponding
attention to the scientific understanding of human behavior and the psychological
and social aspects of illness and patient care.- The average physician today com-
pletes his formal education with impressive capabilities to deal with the more
technical aspects of bodily disease, yet when it comes to dealing with the human
side of illness and patient care he displays little more than the native ability and
personal qualities with which he entered medical school. The considerable body of
knowledge about human behavior which has accumulated since the turn of the
century and how this may be applied to achieve more effective patient care and health
maintenance remains largely unknown to him. Neglect of this important dimension
of the physicians education lies at the root of frequently voiced complaints by
patients that physicians are insensitive, callous, neglectful, arrogant and mechanical
in their approaches.
There undoubtedly are many reasons for this situation, but the most important
is the pervasive influence of the biomedical model of disease. Rasmussen traces the
philosophic origins of this model back three or four centuries when established
Christian orthodoxy lifted the prohibition against physicians dissecting the human
body as long as they did not presume to deal with mans soul, morals, mind and
behavior. This compact helped determine that Western Medicine be based upon
dualism and reductionism. Dualism predicates separation of mind from body, of the
psychological from the somatic, and provides no conceptual framework, other than
reductionism, whereby the two can be related. Reductionism assumes that the under-
standing of a more complex entity can be best achieved by its analysis into its
component parts and therefore that the complexities of life and biological phenomena,
including behavior and mental processes, are to be studied and explained by the
methods and in the language of physics and chemistry. Reductionism fosters a view
of nature as involving interactions of discrete entities in a linear causal fashion,
simple cause-and-effect relationships. This influence is expressed in the habit of
speaking of diseases not as dynamic processes but as discrete entities the elimination
of which awaits only discovery of their causes. The pledge of the ultimate conquest
of disease, upon which biomedicine solicits support from the public, merely panders
* Presented as the 23rd Cartwright Lecture, Columbia University College of Physicians
and Surgeons, November, 1977, under the title, The Biomedical Model: A Procrustean
Bed?
t Supported by grants from the U.S.P.H.S. (MH 14151 and MH 11668) and the Henry
1. Kaiser Family Foundation.
169
0077-8923/78/0310-0169 $01.75/2 0 1978, NYAS
170 Annals New Y ork Academy of Sciences
to a deep-seated human desire for paradise on earth. We are already paying the price
for promises that have not and cannot be fulfilled.
Biomedical Model
Yet it is not to be gainsaid that as a scientific framework within which to elaborate
the disordered bodily mechanisms involved in disease the biomedical model has been
extraordinarily fruitful. But this very success has served not only to entrench
dualism and reductionism but also to encourage its more enthusiastic advocates
to promote the biomedical model as ultimately capable of explaining all aspects of
health and disease. The dogmatism inherent in such blind faith in and exaggerated
claims for the model has been a powerful factor in deflecting scientific interest and
attention from problems that do not readily yield to the biomedical approach. Out-
standing among these have been the more personal, human, psychological and social
aspects of health and disease, the caring rather than curing function of the physician.
These biomedicine considers neither accessible to rigorous scientific evaluation nor
essential for the education of the physician. Small wonder that what patients have
to report and what physicians can observe with their own senses are given less
credence than are data measured in the laboratory or established through sophisti-
cated instrumentation; that many medical students are being awarded their medical
degrees without ever having been supervised in the complete interview and physical
examination of even a single patient; that there is excessive and inappropriate shot-
gun use of laboratory and diagnostic procedures with their corresponding dis-
comfort and cost to patients and increased risk of mishap and malpractice actions;
that patiend feel used, abused, and dehumanized and become resentful of physicians
and the system which subjects them to such experiences; and that physicians feel
bewildered, inept, frustrated and angry when sophisticated instrumentation fails
to yield answers and patients persist in feeling ill and making demands in the face
of the laboratory demonstration of no disease. These are all penalties we are
paying for tolerating the degradation of a productive scientific model into a dogma.
Public Dissatisfaction
As public dissatisfaction with the quality of medical care once again becomes
more vocal and articulate, thoughtful physicians are beginning to question wherein
our present medical educational system is failing to fulfill its responsibility to prepare
physicians satisfactorily to care for the sick. For it is clear that even patients with
ready access to health facilities have complaints about the quality of care they
receive from physicians and medical institutions.6 But so far the main response from
the leaders of American medical education has been a curiously regressive romanti-
cism. Writer after writer pays homage to the triumphs of biomedical science and
urges no compromise in the scientific preparation of the future doctor, but few
seem aware that a major part of the medical students scientific education, namely
that concerned with the human dimensions of illness, has been largely, if not totally
neglected. Instead, the typical response of medical educators to the complaints of
patients and the increasing questions of students and young physicians is to recom-
mend a sentimental return to the past. For them what is required to enable the
physician of tomorrow to escape the alleged dehumanizing influence of science
and acquire the human skills and sensitivities said to characterize the humble
practitioner of old is to expose students earlier to practitioners caring for patients.
Ignored is the necessity to develop scientific principles and to apply the scientific
method to the human dimensions of medicine. The picture naively conjured up is
Engel: Biopsychosocial Model 171
that the scientific competence of todays physician can be blended with the legendary
warmth, compassion and common sense of the kindly family doctor of yesteryear.
Unfortunately, this notion is both false and devoid of logic. There is in fact no
historical support for the claim that physicians of past generations were any more
endowed with compassion and concern than are physicians of today.2 In each era,
whether the 1970s, the 1920s, the 1880s, or the 1850s, one finds physicians of the
preceding generation praised for their humanity while physicians of the day are
accused of insensitivity and ineptness in personal dealings with patients and of
excessive zeal in their application of the therapeutic measures in vogue at the time.
The cry always is that the modern physician has lost the human touch and
become too mechanical or too scientific in his approach.
Furthermore, even less evidence exists to support the claims of those who believe
that mere exposure to or exhortation from an idealized older physician will somehow
or other inculcate better attitudes and result in more effective practices. For no
matter how inspiring a personal example a physician may set for students, without
a scientific understanding of the psychosocial aspects of illness and patient care
the doctors ability to communicate principles upon which others can build will be
limited.
Herein lies the dilemma. For while medicine recognizes the need to be more
responsive to growing public dissatisfaction with how individual care is being pro-
vided, the model upon which medical education and research is based does not include
the patient. The biomedical model is disease-oriented, not patient-oriented. To be
patient-oriented the model must include psychosocial dimensions. But even the
term, psychosocial, has a strange and esoteric ring for biomedically-trained physi-
cians. For most, psychosocial means problems primarily of concern to the psychia-
trist or the social worker. Whatever else has to do with the patient and his care is
classified as the art of medicine and is based on intuition, professional rules,
aphorisms, and maxims from the accumulated wisdom of experienced clinicians. A
recent survey of family practice concluded that emphasis on psychosocial studies
in the education of the family physician is unwarranted, since among 23,000 cases
only 1300 (5.7%) could be classified as psychosocial problems. But in that study
psychosocial problems were defined as problems with psychologic and social
origins and psychologic or social manifestations, and turned out to include only
depression, marital problems and anxiety neurosis, hardly even representative of
psychiatric morbidity. A much better perspective as to what psychosocial encom-
passes can be derived from the complaints of the public about doctors and medical
care, for it is patients and families who are most painfully aware of what is missing.
They are the ones who complain that doctors dont communicate well, that they
dont really listen, that they seem insensitive to personal needs and individual dif-
ferences, that they neglect the person in the zeal to pursue diagnostic and treatment
procedures. They stress the unavailability of the physician and health services,
often as much indicative of psychological remoteness as of economic barriers or
geographical distances.
Different Health Criteria
All of such complaints-and many more-bespeak the publics awareness of
grave deficiencies in the medical establishments knowledge and ability to handle
rationally all that is encompassed in the human experience of being ill. Central to
this gap between medicine and the public it is meant to serve is that the criteria for
health and well-being applied by the patient are fundamentally different from those
172 Annals New York Academy of Sciences
applied by the physician, even though culturally and intellectually both patient and
physician adhere to the biomedical model of disease. For the patient the ultimate
criteria are psychosocial, even when the complaint is physical. Patients criteria
have to do with how one feels, how one functions, how one relates; with the ability
to love, to work, to struggle, to seek options and to make choices. The physician,
in contrast, while ostensibly attentive to such concerns, nonetheless is wont to con-
sider such criteria as merely subjective. For the physician the real criteria for
status and outcome are physical measures, for which increasingly elegant and sensitive
instruments are available. No comparable conceptual tools or intellectual skills are
available for the physician to resolve the discrepancies between what the patient
has to say and what the laboratory has to report. Even the organization of health
care delivery is predicated on the assumption that the doctor, that is, the laboratory,
is right and the patient is wrong.
For hundreds of years Western Medicine has brushed aside the complaints of
patients, yet herein lies the key to what is missing, the understanding of what
comprises the psychosocial dimensions of illness and health care. But as long as the
biomedical model prevails, unscientific and simplistic solutions to resolve the com-
plaints of patients will be promoted. Currently the most seductive holds that since
nothing more than compassion, a humane attitude and good common sense are
required to meet the more personal needs of patients and their families, these
functions can be delegated to other health professionals, leaving diagnosis and treat-
ment of disease to the biomedically qualified physician.
Role of Nurse
For physicians to solicit the assistance of others is hardly novel; medicine has
a long tradition of developing aides with various specialized technical skills and
knowledge to assist physicians in patient care. But there is a subtle difference in
how ancillary health professionals evolved in the past and what is happening today.
For the most part these aides, beginning with the trained nurse in the last century,
evolved from the needs of physicians to perform their functions more efficiently.
Moreover, nurses remained dependent on the doctor for basic medical knowledge
and skills as well as, to a large extent, for the definition of professional tasks and
roles. For example, early nineteenth century nursing care commonly was provided
by women from religious orders in institutions or by female relatives or servants in
the home, often with little or no medical supervision.
As medicine became more scientific and technical, the value of a specially trained
cadre of women to provide nursing services in hospital and at home became obvious.
In this way nursing came under the aegis of medicine rather than religion and the
trained nurse emerged not only to assist the doctor with procedures but also to
implement his orders and to attend to the bodily and personal needs of the sick. As
nursing education became more formalized and nursing achieved status as a profes-
sion, educational and preceptorial roles became increasingly the responsibility of
nurses themselves. And as nurses progressively evolved new roles and activities which
were natural outgrowths of what nurses, rather than doctors, do for and with
patients, nursing achieved a professional identity of its own. And while physicians
could only welcome this extension of the range of nurses competencies and nurses
capacities for independent action and judgment, there rarely was any question that
ultimately the nurses responsibility was to the physician whose patient she was caring
for. For the physician not only had the more extensive educational background
and scientific qualifications, but also the most thorough scientific understanding
of the disease for which the patient came for treatment.
Engel: Biopsychosocial Model 173
But note carefully my language: The physician had the most thorough and scien-
tisc understanding of the dkease for which the patient came for treatment, not the
most thorough and scientific understanding of the patient who came for help. Here
is the crux of the matter: It is now becoming clear that in this one area, the under-
standing of human needs and human behavior, physicians are by no means any
more qualified or competent than are those whose aid they solicit as health care
extenders. In fact, in this understanding neither the physician nor the health care
extender, whether nurse or other, is necessarily much more qualified than any other
reasonably educated, sensitive layperson. Those professionals more knowledge-
able than laypeople in psychosocial matters, namely, the psychiatrist, the psychiatric
nurse, the psychiatric social worker, the clinical psychologist and the mental health
aide, are the exceptions that prove the rule because their professional responsibility
generally includes the care of the mentally ill and the seriously deviant, not the every-
day aspects of patient care.
At the heart of this situation are two factors. The first factor is the apparent
intransigence of the biomedical establishment in its refusal or inability to
consider human behavior as a subject accessible to scientific study and understand-
ing other than in reductionistic terms. This serves to entrench the view, not only
among health professionals but among the general public as well, that no special
training or expertise is required to deal with the human side of patient care. Any-
one can do it or We have always done it are typical but unwarranted claims.
The second factor is the widespread dissatisfaction of many patients and their
families with the quality of personal attention and understanding they receive from
physicians and medical institutions. This has obliged the medical establishment
to consider, even to acknowledge, that a problem exists, that the contributions of
biomedicine, indispensable and remarkable as they are, do not suffice, that some-
thing is missing. To the extent that this constitutes a challenge to critically examine
cherished beliefs, policies and practices and is an inducement to seek new approaches
and solutions, it can only be welcomed. But to the extent that it generates defensive-
ness and provokes an adversary atmosphere, alarm must be expressed.
Adversary Atmosphere
Unfortunately it is the latter, an adversary atmosphere, which is prevailing within
medicine as well as between medicine and other health-related disciplines. The
notion that the diagnosis and treatment of disease should be the responsibility of
physicians while the care of the patient and maintenance of health may be delegated
to other health providers is fostering a dichotomy, well illustrated in a diagram from
a current nursing text.O (FIGURE 1). Even with medicine such a division of tasks is
being promoted. Thus the various primary care disciplines, e.g., family medicine,
general internal medicine and general pediatrics, now fervently proclaim their com-
mitment to the patient, almost as though they had rediscovered compassion and
the art of medicine and had some monopoly on altruistic principle^."^In taking
such a position they unjustifiably equate their wish and motivation to understand
and meet the more personal needs of patients with their actual ability and knowledge
to do so.
Some nurses, too, are militantly laying claim to a superior knowledge and feeling
for the patient, some even arrogating to themselves the responsibility to protect
the patient from the cold, insensitive physician. Unfortunately, this concern
often evolves from the false premise that science and humanism are somehow in
opposition. Such a posture promotes rivalry, if not antagonism, between and among
health professionals. But the care of the sick calls for collaboration and smooth
174 Annals New York Academy of Sciences
FIGURE I . Differing and overlapping focuses of nursing and medicine. The triangles re-
present focus of the nurse and the physician in helping people with health or illness
problems. The shaded area is the area of overlap. Nurses are involved in observation and
care of the patient as related to diagnostic and therapeutic procedures; physicians are con-
cerned with how their therapy affects persons daily functional ability. The cross-hatched
area represents expansion of the nursing focus into responsibility for diagnosis and treatment
of some illness. Bates conceptualized the expanded role of the nurse as encompassing
the nursing focus plus the added medical role (cross-hatched area above) while the physicians
assistant, in contrast, is seen as functioning only within the medical triangle. (From Mitchell.n
By permission of McGraw-Hill.)
interaction between professionals, with complementary roles to fulfill and tasks to
perform. This is impossible as long as the dominant model is one which philosophically
denies the application of science to the care of the patient, places science and
humanism in opposition, and divides health professionals into a superior group
who treat disease and a lesser breed who care for the sick.
No resolution of the above divisive situation will be forthcoming until a model is
developed that can be shared by all who are involved in the care of the sick, one
which encompasses all the elements involved in health and disease, from the molecular
to the psychosocial. Without such a common conceptual framework only more
conflict and chaos will ensue, with the patient the ultimate loser. For the key to
optimal patient care is collaboration, communication and complementarity among
Engel: Biopsychosocial Model 175
all branches of the health professions. Given the varieties of tasks to accomplish
and the differing skills, techniques and approaches required to accomplish them,
collaboration, communication and complementarity are only possible when the
various disciplines share in common a basic set of assumptions and principles. Other-
wise each of the different health professions is tempted to evolve its own more
limited model, suitable for its own purposes, but in practice likely to inhibit col-
laboration, confuse communication and substitute competition for complementarity.
Biopsychosocial Model
To meet the existing need I have proposed guidelines for a more inclusive model,
a biopsychosocial model, based on general systems the~ry.~.l ~-" As the name sug-
gests, its intent is to provide a framework within which can be conceptualized and
related as natural systems all the levels of organization pertinent to health and
disease, from subatomic particles through molecules, cells, tissues, organs, organ
systems, the person, the family, the community, the culture, and ultimately the bio-
sphere.
In nature such organized systems are hierarchically arranged in order of com-
plexity, the simplest and developmentally the oldest being subordinate to the more
complex and developmentally more recent in origin. Thus, processes at the cellular
level are subordinate to those at the tissue or organ level, which in turn are sub-
ordinate to those at the person or community level. Yet while each system in the
hierarchy is functionally integrated and relatively autonomous, it is also interconnected
with every other system by information flow through feedback arrangements.
Hence disturbances at any system level may be communicated to and affect any
other system level, with those in the closest functional relationship likely to be the
first affected.
Predicated on the systems approach, the biopsychosocial model dispenses with
the scientifically archaic principles of dualism and reductionism and replaces the
simple cause-and-effect explanations of linear causality with reciprocal causal models.
Health, disease and disability thus are conceptualized in terms of the relative
intactness and functioning of each component system on each hierarchical level.
Overall health reflects a high level of intra- and intersystemic harmony. Such har-
mony may be disrupted at any level, at the cellular, at the organ system, at the
whole person or at the community levels. Whether the resulting disturbance is con-
tained at the level at which it is initiated or whether other levels become implicated
is a function of the capacity of that system to adjust to change. For example, a
modification in an individual's social environment, impacting first on the psycho-
logical functions of perception and appraisal, may be successfully accommodated
at the psychological level and hence give rise to no perceptible reverberations else-
where. Similarly, a molecular substance introduced into the body might be broken
down, excreted, neutralized or inactivated without implicating any but the particular
molecular, cellular, tissue, or organ system required for its disposal. In both instances
the systems involved have the capacity to handle the imposed change without dis-
ruption.
Yet under different circumstances or with another individual with a different past
history the very same social change or the very same molecules may induce profound
disruptions involving many systems in the hierarchy. Such contrasts between smooth
functioning and disruption provide the basis upon which health, disease, illness and
disability may be differentiated.lO." Central to this perspective are not only the
dynamic interrelations that determine relative degrees of intra- and intersystemic
harmony or disruption, but also the fact that every change becomes part of the
history of each system, rendering it different at every successive point in time. In
176 Annals New York Academy of Sciences
the biopsychosocial model there can be no return to status quo unfe. Health restored
is not the former state of health but represents a different intersystemic harmony
than existed before the illness, with characteristics based on all the system changes
incurred during the illness. By virtue of the illness not only is the individual changed
as a person, but so too may be changed others in relationship to him, in the family
as well as the community (FIGURES 2 and 3)."
The advantages of such a systems-oriented biopsychosocial model over the tradi-
ERE - RESOURCE DRAIN
ISELF-ADJ USTING)
HOMO SAPENS - LOSS OF INDIVIDUAL FROM GENE' POOL
I
I
SOCIETY-NATION -
CHALLENGE TO RESOURCE-ALLOCATION & WELFARE
POLICIES
CHALLENCE TO TRADITIONAL VALUES: DESIRE TO CARE
COMMUNITY - RESOURCES DIVERTED FOR CARE OF SICK INDIVIDUAL
- EMOTIONAL TRAUMA
I
INABILITY TO PERFORM COMPLEX. COORDINATED
- PHYSICAL AND MENTAL ACTIVITIES
ARRESTED DEVELOPMENT
- LACK OF DIRECTIONS FOR DIFFERENTIATION
ORGANELLES - - MUTANT GENE ON CHROMOSOME
I
MOLECULES - ALTERATION OF DNA TEMPLATE
- ELECTRON EXCITATION AND ESCAPE
4-
PHOTON8 OF RADIATION (UPON GAMETE)
PARTICLES
I
WARKS (7)
m:
- ~ n i c ~ prturbti on
-b - R m l t i y Disruption
FIQURE 2. Disease example illustrating the biopsychosocial systems approach. Severe
physical and mental retardation caused by a radiation-induced mutation in the gamete:
example of spread of disruption upward through the hierarchy. (From Brody." By permis-
sion of University of Chicago Press.)
Engel: Biopsychosocial Model 177
BIOSPHERE
I
I
I
I
I
HOME SAPIENS
SOCIETY-NATION POLICY DECISION TO STOP MANUFACTURE OF AIRCRAFT
CHALLENGE TO VALUES LOYALTY TO GOVERNMENT
VS NEEO FOR EMPLOYMENT DISTASTE FOR
3
SUBCULTURE WELFARE PAYMENTS. ETC
COMMUNITY LOSS OF INCOME, OUTWARD MIGRATION
FAMILY ECONOMIC AN0 EMOTIONAL STRESS, ROLE REALIGNMENT
REASSESSMENT OF SELF-WORTH, NEEO TO LEARN
0 EXPERIENCE
SYSTEMS
I
I
I
I
I
I
ORGANS
TISSUES
CELLS
ORGANELLES
MOLECULES
SUBATOMIC
PARTICLES
I
OUARKS 01
DISRUPTION OF RHYTHM OF ENVIRONMENTAL INPUTS
-
SIGNS AND SYMPTOMS OF ORGANIC DISEASE
LETHARGY. PAIN, NAUSEA, ETC
+
- -1
4- = lnotlal ~erturbtlon
- = Rewltin4 Divuoiion
FIOIJRE 3. Another disease example illustrating biopsychosocial medical model. Stress-
related psychosomatic illness in an unemployed aerospace engineer: example of spread of dis-
ruption downward through the hierarchy. (From Brody." By permission University of
Chicago Press.)
tional biomedical model may be illustrated by contrasting the clinical approaches of
adherents of each model. When a patient presents a problem, how the physician
goes about its solution is determined not just by past experience and knowledge
but even more by the working conceptual models in relationship to which the
physician organizes such experience and knowledge. The following is an actual
clinical event that examines how the conceptualizations of a biomedical dualist-
reductionist and a biopsychosocial systematist, respectively, might influence the
approach of each to the same clinical situation:
A 55-year-old real estate salesman was admitted to the Strong Memorial Hospital
Emergency Room with symptoms and findings consistent with the diagnosis of acute
178 Annals New York Academy of Sciences
myocardial infarction. While the intern was attempting an arterial puncture ventricular
fibrillation abruptly developed. The patient was promptly and successfully resus-
citated.
To begin with, the language each uses to characterize and think about the prob-
lem would differ, in itself indicating how differently issues are conceptualized by
each. The biomedical model focuses on the disease as an entity which can be under-
stood and treated independently of the person afflicted. Hence the familiar impersonal
language of the reductionist physician would characterize the problem as a case
of acute myocardial infarction with ventricular fibrillation. In contrast, for the
systematist physician the person must be the primary frame of reference, leading to
a more wordy but also more human and personal reference, e.g.: A middle-aged
real estate salesman with an acute myocardial infarction developed ventricular fibril-
lation while the intern was attempting an arterial puncture. However, note a
salient difference. The reductionist sees the problem as a discrete entity while the
systematist deals with it as part of a series of ongoing dynamic events. Hence for
the systematist even the identifying characterization must include some sense of
sequences and circumstances, that is, the dimensions of time and space.
Of course, when it comes to the acute emergency and how the cardiac arrest
is to be handled, differences between the reductionist and systematist temporarily
vanish. Both institute identical resuscitation procedures, which if successful, would
be followed by efforts to establish the reason for the cardiac arrest. Both, too,
would in subsequent care of the patient attend not only to remote biochemical or
physiological events that might unfavorably affect the function and electrical stability
of the heart but also to remote consequences for other organs of the cardiac mal-
function. But again differences emerge in how each conceptualizes the place of the
patient in these processes.
This is dramatically demonstrated by how the biomedically-oriented staff
responded to the arrest and subsequent successful resuscitation; they congratulated
each other and the patient on the good fortune that he happened to be in the ER
at the time of the arrest! The possibility that the two circumstances may not have
been entirely fortuitious was not even considered.
The systematist physician, in contrast, ever aware of the potential for disrup-
tion at any system level, would always have in mind the possibility that psychological
disruption might be precipitated by the setting of the care, including hidher own
behavior with the patient.
Interview of this particular patient documented this indeed to have been the case.
The dogged persistence of the intern in perservering in his efforts to perform the
arterial puncture, without either explanation to the patient or attention to his dis-
tress and pain, induced intense patient anger and frustration, an abrupt loss of con-
fidence in those providing care, followed by a growing sense of impotence to do any-
thing about the situation in which he found himself.
The occurrence of ventricular fibrillation at that point is in keeping with well-
established knowledge documenting the ability of increased autonomic activity and
calecholamine secretion to lower threshold for ventricular fibrillation in the presence
of an existing substratum of myocardial electrical instability, in this instance based
on myocardial infarction.$
The systematist does not stop with consideration of how perturbations at other
levels might have contributed to cardiac arrest. Of equal concern is how the cardiac
arrest may be impacting or might in the future impact on the stability or instability
of other systems. Thus while the reductionist thinks in terms of cause and effect,
of final consequences and discrete entities, the systematist is thinking in terms of
ongoing, progressive sequences of intra- and intersystemic interactions with the
Engel: Biopsychosocial Model 179
stability of each system being ultimately determined through multilevel feedback
arrangements. And while the reductionist would tend to view restoration of sinus
rhythm as an end in itself, the systematist sees it as a possible source of new perturba-
tions as well as a step toward establishment of new levels of intersystemic harmony.
The experience for the patient of having suffered an arrest is seen by the bio-
medical physician as separate from the disease process. Not so for the biopsycho-
social physician, who not only recognizes that events in the patients life might set in
motion disturbances at the psychological level ultimately capable of affecting the
electrical stability of the heart, but also considers how the personality structure of
the patient might determine such an outcome and how such knowledge may be help-
ful in the patients care.
Whether the patient lives or dies, the biopsychosocial model further provides
the physician with the conceptual tools with which to include in thinking and plan-
ning the implications of the cardiac arrest not only for the patient, but also for
the family, the community, and even for the health care providers as well. Within
the framework of the biopsychosocial, all of these are legitimate as well as assimilable
concerns for those who man the health care system. A biopsychosocial physician
even finds it logical to ask to what extent the death or permanent impairment of
the victim of cardiac arrest might affect the health and well-being of those who
survive, whether they be the family left bereft, the employer deprived of a valuable
worker, or the health care provider who was involved in the unsuccessful attempt
at resuscitation.
It is hoped the example, with all its oversimplications, will indicate how adop-
tion of a biopsychosocial model can contribute to the unity of the health profes-
sions and render collaboration, communication and complementarity a reality rather
than mere sloganeering. Through sharing basic knowledge and a common way of
looking at Man, from the organization of his body to the determinants of his behavior
to the social structures of which he is an integral part, health professionals would
have in common the languages essential for communication and cooperation and for
the complementarity inherent in the need for the special knowledge and skills
required for the many varied activities involved in providing high level health care.
Competence
To buttress collaboration, communication, and complementarity, the fourth in-
dispensible attribute of health care professionals must be competence. How stubborn
and pernicious the influence of biomedical dogma can be is betrayed by those who
say, I fully agree with your position bur, when I get sick I would rather have for
my physician one who is conversant with the most up-to-date biomedical knowledge
and techniques than one who understands my psyche. Again dualism intrudes, as
though competence in one sphere precludes competence in the other. The proper
distinction is between a general level of competence and specialized competencies.
Criteria for specialized competencies already exist for most categories and sub-
categories of the health professions. What is generally lacking now is the require-
ment that general competency include the psychosocial sphere. Current biomedical
dogma designates psychosocial knowledge and skills a special competency, training
for which is expected only of psychiatrists and other mental health professionals.
With the biopsychosocial model as its foundation, general competency for all
health professionals would derive from their shared understanding that all three
levels, biological, psychological and social, must be taken into account in every
health care task. Accordingly, for any particular task the hierarchical arrangement
of responsibilities among the different health professionals should be determined
180 Annals New York Academy of Sciences
by the levels of general competency and the types of special competency possessed
by each of the various professionals available in the setting and at the time.
Thus, for some tasks any health professional, regardless of discipline. might be
compentent, while for other more specialized or complex tasks only a professional
with the knowledge and skills needed for that particular task would be qualified,
be it a speech therapist, a surgeon, a nutritionist, a nurse or a psychiatric social
worker.
Similarly, for tasks that require the collaboration of several professional dis-
CARE OF THE PATIENT
EQUIVALENT COMPETENCY
SUPERIOR COMPETENCY
9pEIpB
CARE OF THE PATIENT
FIOIJRB 4. Task-oriented relationships between doctors and nurses in the care of patients
in terms of the relative competencies of each. The area of equivalent competency applies to
tasks for which either a doctor or nurse would be qualified. Superior competency implies
that both doctor and nurse have a measure of competency to perform a particular task
or exercise a particular judgment, but that education and experience renders one superior
to the other. Unique competency refers to activities which only members of one discipline
or subdiscipline are qualified to carry out. In any particular situation the health professional
most qualified available at that moment is the one to assume responsibility. For the same
problem, under certain circumstances this may prove to be a nurse, under different cir-
cumstances, a physician, depending on individual qualifications and availability.
Engel: Biopsychosocial Model 181
ciplines hierarchical relationships at any point should depend upon which individual,
regardless of discipline, has the superior or unique competency required for that
particular task at that particular time. To illustrate these principles, FIGURE 4 dia-
grams task-oriented relationships between doctors and nurses in the care of patients
in terms of the equivalent, superior and unique competencies of each. Comparable
diagrams may be constructed for relationships between any of the disciplines.
It may be contrasted with the diagram from the nursing text, based on the bio-
medical model, in which tasks involving the patient (daily living) are designated
primarily as nursing responsibilities while those involving disease (diagnosis and
treatment) are designated primarily medical responsibilities, the overlap reduced
almost to the vanishing point. (FIGURE 1).
CONCLUSION
Educators for the health professions are confronted with choices
that could have momentous significance for the future of health care. Educators can
continue to try to force medicine into the Procrustean Bed of the biomedical
model, with all the divisiveness and fragmentation encouraged by its inherent
reductionism and dualism, or they can consider a more comprehensive model that
emphasizes psychosocial skills based on a systems approach, with its potential
to enhance collaboration, communication and complementarity among the various
health professions and enhance the general level of competence of each. That
choice and opportunity is especially crucial for those just beginning their education
because how the health sciences and health care evolve in the future is to a large
degree determined by the approach health profession educators take in training
fledgling providers-to-be.
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